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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610094
Report Date: 03/05/2025
Date Signed: 03/06/2025 08:25:19 AM

Document Has Been Signed on 03/06/2025 08:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WELLNESS ASSISTED LIVINGFACILITY NUMBER:
197610094
ADMINISTRATOR/
DIRECTOR:		MELIKSETYAN, LUSINEFACILITY TYPE:
740
ADDRESS:9115 N WYSTONE AVETELEPHONE:
(747) 218-9141
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ruzanna Manukyan- Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff#1 (S1) and explained the reason for the visit. Staff informed LPA that they were unable to understand English and went inside to wake up Staff#2 (S2). LPA observed S2 sleeping on the couch of the living room. LPA called Administrator LUSINE MELIKSETYAN who could not attend today's visit. Administrator Designee Ruzanna Manukyana arrived shortly after.

At 09:30 AM LPA took a tour of the physical plant. Required postings were observed in the entry area.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the office cabinets. The fire extinguisher is located in the kitchen with a purchase date of 04/11/24. Smoke alarms and carbon monoxide were tested and are functional.


Bedrooms: The facility has four (4) bedrooms of which one is a shared room. All four (4) bedrooms were toured and appear to be clean and properly furnished. LPA observed that staff are using resident closet in Room#2 to store clothes and other personal items. LPA asked S2 for the reason and S2 stated that there's no other place to store their personal items. Bathrooms: There are two (2) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 115.7 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.
Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry room: was locked and inaccessible to residents. Garage: The garage was observed to be only used for storage. (Continue on 809 C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094
VISIT DATE: 03/05/2025
NARRATIVE
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 Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms.Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date. LPA observed that S2 has incomplete LIC 501. Interview with S2 revealed that S2 has insufficient qualifications. LPA also interviewed S1, and S1 couldn't answer any of the LPA's questions due to the language barrier. Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed that medication records are inconsistent with medication audit.

Exit interview conducted, citations issued, appeal rights given, copy of this report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/06/2025 08:25 AM - It Cannot Be Edited


Created By: Mariana Agban On 03/05/2025 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)


This requirement is not met as evidenced by: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. S2 has Insufficient qualifications. LIC 501 is incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administrator will provide proof of suffient qualifications of S2 and email complete LIC 501 to LPA by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/06/2025 08:25 AM - It Cannot Be Edited


Created By: Mariana Agban On 03/05/2025 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(3)
87411-Personnel Requirements - General-(d)(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.,.This requirement is not met as evidenced by
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above. S1 couldn't answer any of LPA's questions. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administrator/Licensee agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 03/06/2025 08:25 AM - It Cannot Be Edited


Created By: Mariana Agban On 03/05/2025 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS ASSISTED LIVING
FACILITY NUMBER: 197610094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed that staff are using resident closet in Room#2 to store clothes and other personal items which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administrator will remove all staff clothes and personal items from Resident closet. Administrator will email a picture by the POC date.
Type B
Section Cited
CCR
87465(d)(2)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above. LPA observed that medication records are inconsistent with medication audit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2025
Plan of Correction
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Administrator will provide accurate medication records by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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